Early computed tomography for acute post-traumatic diffuse axonal injury: a systematic review.

PURPOSE: Diffuse axonal injury (DAI) is the rupture of multiple axons due to acceleration and deceleration forces during a closed head injury. Most traumatic brain injuries (TBI) have some degree of DAI, especially severe TBI. Computed tomography (CT) remains the first imaging test performed in the acute phase of TBI, but has low sensitivity for detecting DAI, since DAI is a cellular lesion. The aim of this study is to search in the literature for CT signs, in the first 24 h after TBI, that may help to differentiate patients in groups with a better versus worst prognosis. METHODS: We searched for primary scientific articles in the PubMed database, in English, indexed since January 1st, 2000. RESULTS: Five articles were selected for review. In the DAI group, traffic accidents accounted 70% of the cases, 79% were male, and the mean age was 41 years. There was an association between DAI and intraventricular hemorrhage (IVH) and traumatic subarachnoid hemorrhage (tSAH); an association between the IVH grade and number of corpus callosum lesions; and an association between blood in the interpeduncular cisterns (IPC) and brainstem lesions. CONCLUSION: In closed TBI with no tSAH, severe DAI is unlikely. Similarly, in the absence of IVH, any DAI is unlikely. If there is IVH, patients generally are clinically worse; and the more ventricles affected, the worse the prognosis.

Associations of Antithrombotic Timing and Regimen with Ischemic Stroke and Bleeding Complications in Blunt Cerebrovascular Injury.

BACKGROUND: Blunt cerebrovascular injuries (BCVIs) are associated with long-term neurological effects. The first-line treatment for BCVIs is antithrombotics, but consensus on the optimal choice and timing of treatment is lacking. METHODS: This was a retrospective study on patients aged at least 18 years admitted to 6 level 1 trauma centers between 1/1/2014 and 12/31/2017 with grade 1-4 BCVI and treated with antithrombotics. Differences in treatment practices were examined across the 6 centers. The primary outcome was ischemic stroke, and secondary outcomes were related to bleeding complications: blood transfusion and intracranial hemorrhage (ICH). Treatment characteristics examined were time to diagnosis and first computerized tomography angiography, time of total treatment course, time on each antithrombotic (anticoagulants, antiplatelets, combination), time from hospital arrival to antithrombotic initiation, and treatment interruption, i.e., treatment halted for a surgical procedure and restarted postoperatively. Chi-square, Fisher exact, Spearman's rank-order correlation, Wilcoxon rank-sum, Kruskal-Wallis, and Cox proportional hazards models with time-varying covariates were used to evaluate associations with the outcomes. RESULTS: A total of 189 patients with BCVI were included. The median (IQR) time from arrival to antithrombotic initiation was 27 (8-61) hours, and 28% of patients had treatment interrupted. The ischemic stroke rate was 7.5% (n = 14), with most strokes (64%, n = 9) occurring between arrival and treatment initiation. Treatment interruption was associated with ischemic stroke (75% of patients with stroke had an interruption versus 24% of patients with no stroke; P < .01). Time on anticoagulants was not associated with ischemic stroke (P = .78), transfusion (P = .43), or ICH (P = .96). Similarly, time on antiplatelets (P = .54, P = .65, P = .60) and time on combination therapy (P = .96, P = .38, P = .57) were not associated with these outcomes. CONCLUSIONS: The timing and consistency of antithrombotic administration are critical in preventing adverse outcomes in patients with BCVI. Most ischemic strokes in this study population occurred between arrival and antithrombotic initiation, representing events that may potentially be intervened upon by earlier treatment. Future studies should examine the safety of continuing treatment through surgical procedures.

Traumatic Minor Intracranial Hemorrhage: Management by Non-neurosurgeon Consultants in a Regional Trauma Center is Safe and Effective.

BACKGROUND: There is debate concerning the need for specialist neurosurgical transfer of patients presenting to Level II trauma centers with a minimal head injury (Glasgow Coma Scale ≥13) and a small non-progressive intracranial bleeding (ICB). METHODS: A retrospective chart analysis was performed assessing the outcomes of adult patients presenting with a minor traumatic ICB on initial CT scan (minimal subarachnoid hemorrhage; small-width subdural hematoma without shift; punctate cerebral contusion). Patients with extradural hematomas and those patients on antiplatelet or anticoagulant therapy were excluded from the protocol. RESULTS: Overall 291 cases were assessed (mean age 69.9 years) with 75% of cases presenting after a fall. There was deterioration of neurological status in 11 patients (3.8%) with 8 hospital transfers and 5 with an abnormal neurological examination (NE). Two patients with an abnormal INR and a worsening head CT were transferred without neurosurgical intervention. Of the 8 transferred cases there were 2 deaths (both >90 years of age with multiple comorbidities) with one craniotomy performed for a subdural hematoma (with full recovery). Three patients meeting transfer criteria were not transferred with one death (patient >90 years of age with severe dementia). The remaining 2 patients were discharged with normal neurological outcomes. CONCLUSIONS: Patients with a minimal traumatic brain injury and a non-progressive minor ICB may be safely managed in a Level II trauma center by an acute care consultant with neurosurgical consultation but without the need for neurosurgical transfer. LEVEL OF EVIDENCE: Retrospective analysis: Level IV.

Acute post-traumatic hydrocephalus in children due to aqueductal obstruction by blood clot: a series of 6 patients.

INTRODUCTION: Post-traumatic hydrocephalus following head injury is a well-known entity. Most cases occur in patients with severe head injuries, often following decompressive craniectomy. On the contrary, acute post-traumatic hydrocephalus, caused by aqueductal obstruction by a blood clot, following mild head injury is uncommon. CLINICAL MATERIAL: Six patients aged between 6 and 15 months presented hydrocephalus secondary to a blood clot in the aqueduct. Because of intracranial hypertension at presentation, 4 patients were urgently treated with external ventricular drains (EVDs). Post-operative course was uneventful. In 2 cases, EVDs were removed without further treatments. In 2 cases, hydrocephalus recurred. These patients were successfully treated with endoscopic third ventriculostomy. The remaining two patients developed symptoms a few days after the trauma. One, that presented hydrocephalus at imaging, was managed with a ventriculo-peritoneal shunt; the other, that presented subdural hygroma, was managed with subduro-peritoneal shunt that was removed later. All patients had complete recovery. DISCUSSION AND CONCLUSION: Hydrocephalus secondary to clot in the aqueduct may rarely be the result of mild head injury in young children. Usually, prompt surgical management warrants a very good outcome. Most children may be treated without a permanent shunt, by using external drains and endoscopic third ventriculostomy.

Decreasing the Cerebral Edema Associated with Traumatic Intracerebral Hemorrhages: Use of a Minimally Invasive Technique.

Traumatic brain injury (TBI) is a major public health problem worldwide that affects all age groups. In the United States alone, there are approximately 50,000 deaths from severe traumatic brain injuries each year. In most studies, about 40 % of severe TBI have associated traumatic intracerebral hemorrhages (tICHs). The surgical treatment of tICH is debated largely because of its invasive nature, particularly in reaching deep tICHs. tICHs have a clear contribution to mass effect and exacerbate cerebral edema and ICP because of the break-down products of hemorrhage. We introduce a modification of the Mi SPACE technique (Minimally Invasive Subcortical Parafascicular Transsulcal Access for Clot Evacuation) that is applicable to tICH. In brief, this technique utilizes a trans-sulcal, stereotactic-guided technique in which a specially designed cannula is used to introduce a 13.5-mm-diameter tube into the epicenter of the tICH. We identified eight tICHs that were treated entirely or in part with the modified Mi SPACE technique during the time period from August 15, 2014 to December 15, 2014. This modified technique was readily deployed safely and efficaciously with significant removal of the tICH as demonstrated by postoperative CT scans. The removal of tICH using this minimally invasive technique may help with the control of ICP and cerebral edema.

Unusual persistent primitive trigeminal artery with a superior duplicated basilar system.

A 67-year-old patient who presented with a right cerebellar hemorrhage underwent vascular workup for suspicion of underlying vascular anomalies. A diagnostic cerebral angiogram demonstrated a duplicated basilar system fed solely by a persistent primitive trigeminal artery. The findings proved to be incidental and unrelated to the patient's hemorrhage. These developmental abnormalities are consistent with embryological development.

Developing, Implementing, and Evaluating a Nurse-Driven Rapid Reversal Protocol for Patients With Traumatic Intracerebral Hemorrhage in the Presence of Preinjury Warfarin.

Warfarin-related traumatic intracerebral hemorrhage (ICH) is often fatal, yet timely evaluation and treatment can improve outcomes. Our study describes the process of developing and implementing a protocol to guide the care of patients with traumatic brain injury (TBI) on preinjury warfarin developed by nurses across several service lines at our Level I trauma center over a 6-month period. Further, we evaluated its efficacy by examining records of adult patients with TBI on preinjury warfarin admitted 1 year before and after protocol implementation. Efficacy was defined as activation rates, receipt and time to head computed tomography (CT) scan and international normalization ratio (INR), and receipt and time to fresh frozen plasma (FFP) administration in patients with ICH with an INR more than 1.5, as per protocol. A subset analysis examined patients with and without an ICH. Outcomes were compared using univariate analyses. One hundred seventy-eight patients were included in the study; 90 (50.6%) were admitted before and 88 (49.4%) after implementation. After implementation, there were improvements in activation rates (34.4% vs. 65.9%; p < .001), the frequency of head CT scans (55.6% vs. 83.0%; p < .001), time to INR (24.0 min vs. 15.0 min; p < .05), and, for patients with ICH with an INR 1.5 or more, decreased time to FFP (157.0 vs. 90.5; p < .05). In conclusion, our protocol led to a more efficient process of care for patients with TBI on warfarin. We believe the implementation process, managed by a dedicated group of nurses across several service lines, substantially contributed to the success of the protocol.

Acute alcohol intoxication, diffuse axonal injury and intraventricular bleeding in patients with isolated blunt traumatic brain injury.

OBJECTIVE: The influence of blood alcohol level (BAL) on outcome remains unclear. This study investigated the relationships between BAL, type and number of diffuse axonal injury (DAI), intraventricular bleeding (IVB) and 6-month outcome. METHODS: This study reviewed 419 patients with isolated blunt traumatic brain injury. First, it compared clinical and radiological characteristics between patients with good recovery and disability. Second, it compared BAL among DAI lesions. Third, it evaluated the correlation between the BAL and severity of IVB, number of DAI and corpus callosum injury lesions. RESULTS: Regardless of BAL, older age, male gender, severe Glasgow Coma Scale score (<9), abnormal pupil, IVB and lesion on genu of corpus callosum were significantly related to disability. There were no significant differences between the BAL and lesions of DAI. Simple regression analysis revealed that there were no significant correlation between BAL and severity of IVB, number of DAI and corpus callosum injury lesions. CONCLUSIONS: Acute alcohol intoxication was not associated with type and number of DAI lesion, IVB and disability. This study suggested that a specific type of traumatic lesion, specifically lesion on genu of corpus callosum and IVB, might be more vital for outcome.

[Hemorrhagic infarction complicated by obliteration of the superior sagittal sinus by depressed skull fracture after a hammer injury: a case report].

The authors have encountered a case of compound depressed skull fracture in a 59 year-old-man complicated by occlusion of the anterior 1/3 part of the superior sagittal sinus (SSS). He was hit by a hammer at the midline of the frontal region, and transferred to our emergency care unit. On admission, there was laceration of skin at the midline of the forehead, but the patient had no neurological deficit. Skull radiograph showed a depressed skull fracture over the SSS. Computed tomography (CT) scan showed a small brain contusion adjacent to the depressed fracture. Digital subtraction angiography (DSA) showed occlusion of the anterior 1/3 part of SSS, and extravasations of contrast medium from cortical arterioles and capillaries. CT taken at 4 hours after injury showed enlargement of the lesion with extravasations of contrast medium and the patient manifested consciousness disturbance at this point. Distribution of extravasations suggested the occurrence of hemorrhagic infarction. Elevation of the depressed skull was thus performed under general anesthesia. There was laceration of the dura 5 mm away from the SSS and lacerations of cortical vessels, but there was no apparent damage to SSS itself. The depressed bone was replaced with artificial bone. The patient was discharged without any neurological deficit. Preoperative angiography was helpful to understand the hemodynamics and risk of massive bleeding during the operation.

[Measurement of intracranial hematoma volume by personal computer].

OBJECTIVE: To explore the method for intracranial hematoma volume measurement by the personal computer. METHODS: Forty cases of various intracranial hematomas were measured by the computer tomography with quantitative software and personal computer with Photoshop CS3 software, respectively. the data from the 2 methods were analyzed and compared. RESULTS: There was no difference between the data from the computer tomography and the personal computer (P>0.05). CONCLUSION: The personal computer with Photoshop CS3 software can measure the volume of various intracranial hematomas precisely, rapidly and simply. It should be recommended in the clinical medicolegal identification.

Traumatic intraventricular hemorrhage with a good prognosis.

We report a 10-year-old girl with an isolated traumatic intraventricular hemorrhage following a traffic accident, who had a good prognosis. Her neurological examination upon arrival was normal and she had no complaint other than headache and vomiting. Computed tomography on admission showed a hemorrhage in the lateral and fourth ventricles. She had a Glasgow Coma Score of 15, and she was thus given only antiepileptic drugs for prophylaxis and followed. Computed tomography that was repeated 5 days after admission showed no blood and all ventricles were of normal size. There was no vascular pathology on magnetic resonance imaging and magnetic resonance angiography. The patient remains well 5 months after her accident. Intraventricular hemorrhage does not always have a poor prognosis.

Connection between traumatic frontal intracerebral hemorrhage and lower urinary tract symptoms.

OBJECTIVE: There have been no previous studies of urinary symptoms in patients with traumatic frontal intracerebral hemorrhage. The purpose of this work was to provide first insights into the potential role of traumatic frontal intracerebral hemorrhage in the development of urinary symptoms. This condition is known to cause compression in and around the prefrontal cortex, and we wanted to examine its effect on the micturition center. PATIENTS AND METHODS: Patients with voiding dysfunction (n = 176) were assessed for lower urinary tract symptoms using the International Prostate Symptom Score (IPSS). Out of 176 patients, 52 symptomatic patients with voiding difficulties underwent urodynamic testing. All patients with traumatic frontal intracerebral hemorrhage were treated at the University Medical Center Tuebingen, Germany, and the Azad University of Medical Sciences in Tehran, Iran, between 2017 and 2020. Lower urinary tract symptoms (LUTS) were documented in patients with compression of the frontal lobe due to local hemorrhage. All patients routinely performed Brain CT scans. Brain magnetic resonance (MRI) images of the patients with suspicion of diffuse axonal injuries were additionally performed. Out of 176 treated patients (median age of 49 years), 52 patients with voiding difficulties were evaluated. RESULTS: Urodynamic testing of 52 symptomatic patients revealed detrusor overactivity in 25 (48%), low-compliance bladder in 4 (7.7%), detrusor-sphincter dyssynergia in 20 (38%), and uninhibited sphincter relaxation in 11 patients (21%). There was no significant correlation between the volume of hemorrhage and urinary symptoms (p=0.203, Spearman q=0.726). Frontal intracerebral hemorrhage compressing the pre-frontal cortex influences the micturition center and is responsible for lower urinary tract symptoms. CONCLUSIONS: Hemorrhage of the right or left frontal lobe does have a direct relationship with incontinence which completely disappeared in 85% of the patients within 9 months.

Assessing the efficacy of mild traumatic brain injury management.

OBJECTIVE: Intracranial hemorrhage (ICH) is frequently found on computed tomography (CT) after mild traumatic brain injury (mTBI) prompting transfer to centers with neurosurgical coverage and repeat imaging to confirm hemorrhage stability. Studies suggest routine repeat imaging has little utility in patients with minimal ICH, no anticoagulant/antiplatelet use, and no neurological decline. Additionally, it is unclear which mTBI patients benefit from transfer for neurosurgery consultation. The authors sought to assess the clinical utility and cost effectiveness of routine repeat head CTs and transfer to tertiary centers in patients with low-risk, mTBI. METHODS: Retrospective evaluation of patients receiving a neurosurgical consultation for TBI during a 4-year period was performed at a level 1 trauma center. Patients were stratified according to risk for neurosurgical intervention based on their initial clinical evaluation and head CT. Only patients with low-risk, mTBI were included. RESULTS: Of 531 patients, 119 met inclusion criteria. Eighty-eight (74.0 %) received two or more CTs. Direct cost of repeat imaging was $273,374. Thirty-seven (31.1 %) were transferred to our facility from hospitals without neurosurgical coverage, costing $61,384. No patient had neurosurgical intervention or mTBI-related in-hospital mortality despite enlarging ICH on repeat CT in three patients. Two patients had mTBI related 30-day readmission for seizure without ICH expansion. CONCLUSION: Routine repeat head CT or transfer of low-risk, mTBI patients to a tertiary center did not result in neurosurgical intervention. Serial neurological examinations may be a safe, cost-effective alternative to repeat imaging for select mTBI patients. A large prospective analysis is warranted for further evaluation.